Notes on Anatomy and Physiology: Degenerative Disc Disease

Let’s continue with the examination of intervertebral discs begun in the last post. This will also give us a chance to examine some of the normal changes associated with aging of the spine and to have a look at degenerative disc disease, a difficulty frequently encountered in the lumbar region.

Many mysteries remain about how the spine actually works. But because low back pain is common, the intervertebral discs of the lumbar spine have been extensively studied. One of the things well established is the varying pressure generated within a normal lumbar disc as the spine moves with the activities of daily life. This information helps us think about preventing disc disease and how to avoid aggravating an already established disc injury.

Fig 1 Two studies of the pressures generated within a lumbar disc during the usual activities and postures of life. The disc pressure experienced when the person is simply standing is taken to be 100. Neumann, 2010, page 331

The above chart points out several things of interest

Notes on Anatomy and Physiology: The Intervertebral Discs

The intervertebral discs play a key role in the life of the healthy spine. Their degeneration is a frequent cause of pain and disability, and a herniated lumbar disc represents the most common reason adults end up with back surgery. And many students first come to the Taoist Tai Chi™ internal arts of health because of persistent back pain.

So, let’s spend a bit of  time reviewing disc structure and behaviour.

As mentioned before, 24 vertebrae stack one on top of the other to connect head to pelvis. Between each pair we find an interposed disc – starting at the junction of the second cervical vertebrae with the third (C2-3) and running all the way down to the joint between the fifth lumbar vertebra and sacrum (L5-S1).

The discs, made of strong but deformable soft tissue, separate the vertebral bodies from one another, thus allowing movement between them.

Fig 1 A soft disc capable of changing shape is placed between adjacent vertebrae. This permits the rocking motion required for forward, back and side bending of the spine. Bogduk, 1987, page 14

The following cartoon gives you a quick sense of how the discs work as spacers between vertebral bodies.

Fig 2 The intrinsic, hydrostatic pressure of the liquid centre of the disc separates the vertebral bodies and tautens the fibers of the annulus fibrosus. Cailliet, 2004, page 34

As we’ll see shortly, the discs also serve as shock absorbers and transmit a loading force from one vertebra to the next.

Each disc has 3 components:

• the nucleus pulposus located towards the centre of the disc. In young people, this material is a gel made mostly of water, giving it the consistency of toothpaste. As a ball of fluid, it deforms with weight-bearing but cannot be compressed. Apply pressure and the nucleus changes shape – without any reduction in its total volume. Pressure exerted on the disc is transmitted radially, much like a compressed water balloon stretches out its walls in all directions.
• the annulus fibrosus: 10-20 densely packed, concentric rings of collagen fiber strands that surround and contain the liquid nucleus like dough encircles the jelly of a doughnut. The collagen fibers arrange themselves in a fixed pattern: their direction alternates in successive rings from left to right, always maintaining an orientation of about 65 degrees off vertical.
• the vertebral endplates. These cartilaginous caps of connective tissue cover most of the top and bottom surfaces of the vertebral bodies. Although tightly bound to the disc by the collagen fibers of the annulus, the endplates are only loosely bound to the vertebral bodies.

Fig 3 The intervertebral disc is shown lifted up somewhat in order to reveal the endplate. Neumann, 2010, page 329

Fig 4 The annulus fibrosus with the nucleus pulposus removed. The collagen fibers are arranged in multiple concentric layers with consecutive rings running in alternating directions, left and then right, but always with an orientation of 65 degrees. Neumann, 2010, page 329

Fig 5 The collagen fibers of the annulus attach the endplate firmly to the disc. Neumann, 2010, page 330

When loaded from above, the height of the nucleus is reduced. It attempts to expand out against the annulus and the collagen rings of the annulus are stretched. The radial pressure exerted by the nucleus is quickly balanced by the elastic tension that develops in the lengthening fibers of the annulus. As a consequence, a 40 kg load produces in a healthy disc only 1 mm of vertical compression and 0.5 mm of radial expansion.

Fig 6 Compression force from body weight and muscle contraction (straight arrows) raises the pressure in the nucleus. This, in turn, increases the tension in the annulus (curved arrows). Neumann, 2010, page 331

At the same time, the nucleus is constrained in the up-down sense by the endplates and vertebral bodies.

Fig 7, B Increased tension in the annulus inhibits radial expansion of the nucleus. The rising pressure in the nucleus is also exerted upward and downward against the vertebral endplates. C The weight is partly borne by the annulus and nucleus and is then transmitted across the endplates to neighbouring vertebrae. Neumann, 2010, page 331

In this way, pressure applied to the nucleus is passed on to both the annulus and the endplates. The fibers of the annulus are braced and prevented from buckling. The disc works as a shock absorber when the spine experiences a rapidly applied force; the force can be momentarily diverted into the annulus, easing the speed with which it must be transmitted down the chain of vertebrae.

Pressure exerted on the endplates transmits part of the load from one vertebra to the next. The facet joints described in the last post also take some of the strain, as do the ligaments, tendons, muscles and thoracolumbar fascia of the back. Compressive forces end up being shared by multiple structures so that no single tissue risks injury. But to work well together this way, all tissues need to stay healthy.

With the removal of a loading force, the elastic energy stored in the collagen rings causes the annulus to recoil and the normal shape of the nucleus is restored.

In the next post, we will look at the pressures to which the discs are typically subjected, some of the changes associated with aging of the spine, and the development of degenerative disc disease.

1. Clinical Anatomy of the Lumbar Spine and Sacrum, Nikolai Bogduk, 1987, Churchill Livingstone, ISBN 0 443 06014 2

2. The Illustrated Guide to Functional Anatomy of the Musculoskeletal System, Rene Cailliet, 2004, AMA press, ISBN 1-57947-408-X

3. Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation, Second Edition, Donald A. Neumann, 2010, Mosby Elsevier, ISBN 978-0-323-03989-5

Bruce McFarlane, MD

© 2010, Taoist Tai Chi Society of Canada

Notes on Anatomy and Physiology: The Vertebrae

The last post examined the spinal column and the central role it plays in everyday life. We will now turn to the small bones that make up this column – the vertebrae.

The 24 vertebrae that connect skull to sacrum vary greatly in shape and function. They do, however, share 2 major features: a vertebral body in front and a vertebral arch behind.

Fig 1 Views of a typical vertebra, the 6th thoracic, from above (on the left) and from the side (on the right). You see the vertebral body out in front; the vertebral arch and its attachments lie behind. Note that the superior facets of one vertebra, facing backwards, are designed to overlap with the forward facing inferior facets of the vertebra above. Like shingles on a roof. Netter, 2006, Plate 154

Each vertebral body is a box-shaped block of bone with essentially flat surfaces top and bottom. An outer shell of solid, cortical bone surrounds an internal space occupied by a web of trabecular bone – thin bony struts that run both vertically and across. This design provides a lightweight structure that involves a minimum of material (bone) in its construction. And yet the structure is strong and able to resist collapse when asked to bear the body’s weight.

The spaces between the trabeculae allow room for blood vessels and nerves to flow through the bone. As well, in some bones, these cavities contain marrow – sites for the production of the red cells, white cells and platelets.

Fig 2 The vertical (VT) and transverse (TT) trabeculae, seen in white, are the struts of the vertebral body that prevent its collapse when loaded. Bogduk, 1997, page 7

Fig 3 A: With just an outer shell of cortical bone, the vertebral body would collapse, once loaded, like an empty cardboard box. C: Internal vertical struts brace the box. E: Transverse connections develop tension when a load is applied and keep the vertical struts from bowing. Bogduk, 1997,page 7

This combination of outer, dense cortical bone and inner cancellous bone (a mesh of branching bony struts and hollows) is such an effective model for the construction of bone that